INV 172A, Record of Complaint Form

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INV 172A, Record of Complaint Form Powered By Docstoc
					                                                                   INVESTIGATIONS

A Public Service Agency                        RECORD OF COMPLAINT FORM
                                                New Text


     READ THE ATTACHED BROCHURE BEFORE COMPLETING YOUR COMPLAINT. NOT ALL COMPLAINTS ARE
     INVESTIGATED

Instructions:	 Type	 or	 print	 the	 following	 information	 for	 the	 person	 filing	 the	 complaint	 and	 the	 Business/Seller	 the
	              complaint	is	against.
	                      Name	              —	 First	name,	middle	initial(s)	and	last	name
	                      Address	           —	 Street,	town/city	and	zip	code
	                      Telephone	numbers	 —	 Area	code	and	number(s)	where	you	can	be	called	during	the	day	and	evening


I.     COMPLAINANT (Person Filing Complaint)
NAME (FIRST, MIDDLE INITIAL(S), LAST)



STREET OR P. O. BOX                                                        APT. NUMBER                    DRIVER LICENSE OR IDENTIFICATION NUMBER



CITY                                                                       STATE                                                 ZIP CODE



DAY TELEPHONE NUMBER                                                       EVENING TELEPHONE NUMBER



SIGNATURE                                                                  DATE




II. BUSINESS/SELLER COMPLAINT IS AGAINST
NAME (FIRST, MIDDLE INITIAL(S), LAST)



STREET OR P. O. BOX                                                        TELEPHONE NUMBER



CITY                                                                       STATE                                                ZIP CODE



DID YOU SEND A PREVIOUS COMPLAINT TO DMV AGAINST THIS BUSINESS/SELLER?     IF YES, WHEN?




May	we	show	a	copy	of	your	complaint	to	the	business/seller? ...............................................................       Yes          No

If	the	transaction	occurred	at	a	location	different	than	the	business	address	above,	please	list	it	here.

Address:

III.	 VEHICLE	INFORMATION	 Write	the	license	plate	number	and	vehicle	identification	number	as	they	are	shown	
      on	the	contract	between	the	buyer	and	seller.
	     Enter	the	purchase	date	(same	as	when	the	contract	was	signed).
YEAR                    MAKE                     MODEL                     LICENSE PLATE NUMBER                                 STATE



VEHICLE IDENTIFICATION NUMBER (VIN)                                        PURCHASE DATE




IV. COMPLAINT                Explain the details of this complaint.




INV 172A (REV. 1/2007) WWW
                                        SEE OTHER SIDE FOR ADDITIONAL SPACE AND INFORMATION
                                                                                           Go to Page 2             Clear Form                 Print
IV. COMPLAINT (continued)
                       IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL SHEETS OF PAPER




V.    MAILING DIRECTIONS

	     To	help	explain	the	details	of	your	complaint,	YOU MUST SUPPLY PHOTOCOPIES OF THOSE DOCUMENTS RELATED TO YOUR
      COMPLAINT. (Include:	 contracts,	warranties,	receipts,	cancelled	checks,	repair	orders,	photographs,	letters)

                                          —DO NOT SEND ORIGINAL DOCUMENTS—

                     PHOTOCOPy THE COMPLETED COMPLAINT. KEEP A COPy FOR yOuR RECORDS.

                    •	 Mail	the	complaint	and	copies	of	supporting	documents	to	the	Investigations	Office
                                   closest	to	where	the	incident	took	place	(see	list	below).


                               FAILURE TO SEND SUPPORTING DOCUMENTS
                               MAY DELAY REPONSE TO YOUR COMPLAINT

VI.      DEPARTMENT OF MOTOR VEHICLES INVESTIGATIONS DISTRICT OFFICES
                      CITY                             STREET ADDRESS                               ZIP CODE
	                Anaheim	                         2450	East	Lincoln	Avenue,	#120	                   92806-4990
	                Artesia	                         17100	South	Pioneer	Boulevard,	#320	              90701-2700
	                Bakersfield	                     7000	Schirra	Court	                               93313-2117
	                Campbell	                        440	Darryl	Drive	                                 95008-0939
	                Canoga	Park	                     6800	Owensmouth	Avenue,	#365	                     91303-2090
	                Chula	Vista	                     30	North	Glover	Avenue	                           91910-1040
	                Los	Angeles	(Culver	City)	       11400	West	Washington	                            90066-6089
	                El	Monte	                        3204	Rosemead	Boulevard,	#202	                    91731-2912
	                Fresno	                          2510	S.	East		Avenue,	#100B	                      93706-8007
	                Hayward	                         1314	West	Winton	Avenue	                          94545-1408
	                Inglewood	                       621	North	La	Brea	Avenue	                         90302-3099
	                Irvine	                          18231	McDurmott	West,	#100	                       92614-6720
	                La	Mesa	                         7777	Alvarado	Road	#616	                          91941-2953
	                Los	Angeles	(Lincoln	Park)	      3529	North	Mission	Road	                          90031-3120
	                Los	Angeles	                     3615	South	Hope	Street	                           90007-4370
	                Rancho	Cucamonga	                8632		Archibald	Avenue,	#108	                     91730-4455
	                Riverside	                       6296	Rivercrest	Drive,	#A	                        92507-0738
	                Roseville	                       151	North	Sunrise	Avenue,	#1006	                  95661-2930
	                Sacramento	                      8259	Demetre	Avenue,	 MS/L219	                    95828-0932
	                San	Diego	                       4375	Derrick	Drive	                               92117-4990
	                San	Francisco	                   5	Thomas	Mellon	Circle,	#168	                     94134-2594
	                San	Bernardino	                  1845	Business	Center	Drive,	#210	                 92408-3447
	                Santa	Rosa	                      2570	Corby	Avenue	                                95407-6005
	                Stockton	                        510	East	Magnolia	                                95202-2314
	                Vallejo	                         200	Couch	Street	                                 94590-2904
	                Ventura	                         1732	Palma	Drive,	#202	                           93003-5717
	                West	Covina	                     800	South	Glendora	Avenue,	Rm-100	                91790-4201


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                                                                                                            INV 172A (REV. 1/2007) WWW